Improving Care for the End of Life, Online Edition The Palliative Care Policy Center

Sourcebook : Improving Care for the End of Life : 9.2 Medicare Payments for Physician Services

Medicare usually pays physicians for procedures and for what it calls "evaluation and management" services (E&M), a category under which payment for most patients with advanced, long-term illness is likely to come. Each E&M bill requires two codes: one for diagnosis and one for how extensive the service was. The diagnosis codes extend to every patient setting, but the coding for how extensive the services were varies by the setting and by whether the service is an ongoing one for an established patient or a first assessment of a patient. Medicare puts many limitations on the frequency of billing possible, but none of these is peculiar to seriously ill patients. (For more basic billing information, go to or

Documentation in the medical record about the work involved for a patient - the systems affected, time spent, and complexity - determines coding for how extensive the service provided was. This process has been a flash point for fraud and abuse investigations. As a result, fiscal intermediaries, the Health Care Financing Administration (HCFA), and medical groups are working out guidelines for review. Managers and planners will have to stay current on the issue as it evolves.

Most patients with advanced illness will have several diagnoses that require many medications; many will be relying on family caregivers, who must bear the stress of caregiving and of loss; and patients themselves must face with their own emotional and spiritual concerns as they approach the end of life. It is likely that the billing profiles of physicians who specialize in serving this population will be quite different from their colleagues whose patients do not have serious and complex illness. For example, an oncologist whose patients have an array of cancer diagnoses will have many short checkup visits that balance the longer visits very sick patients require. An oncologist whose practice focuses solely on patients with advanced illness will bill primarily for longer visits. Because such disparity tends to invite scrutiny, physicians in this area must attend to the need for careful documentation and billing. Without it, a review by the fiscal intermediary might well precipitate billing denials and fraud allegations.

Physician claims are sometimes denied because two physicians practicing in the same specialty cannot bill for ongoing services to the same patient at the same time. Because physicians who focus on treating seriously ill and dying patients have no specialty recognition, this claim restriction is a particular problem. In the previous example, the general oncologist and the oncologist who specializes in advanced illness are both oncologists. If the general oncologist wants his colleague to see the patient as well, that claim might be denied unless the bill uses appropriate E&M codes that differentiate between the services.

This restriction is especially problematic for the general internists and family physicians who typically serve hospices. Despite their substantial expertise in working with patients at the end of life, they cannot advise their physician colleagues who have the same "specialty" training. Often, billing for the symptom by the palliative care physician and for the underlying illness by the primary physician is sufficient.

This problematic billing restriction means that physicians or managers interested in developing palliative care services should first contact their Medicare intermediary. Some intermediaries will allow exceptions and approve concurrent care by two physicians in some circumstances if the service can be proved (sometimes on a special documentation form) to be fundamentally different.

Know the Codes

Palliative care billing codes are those used for initial hospital care--99221, 99222, 99223, (along with the patientís ICD-9 diagnosis). As with other services, the intensity of the visit escalates the coding. A palliative care doctor would bill a moderately complex inpatient visit for a patient with congestive heart failure as 99222 (with an ICD-9 of 428.0).

Any subsequent palliative care consults are billed as subsequent hospital in-patient services, 99231, 99232, or 99233.

9.2.1 Case Study - Northwestern Memorial Hospital
9.2.2 Case Study - Mt. Sinai Hospital
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ ].

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